Provider Demographics
NPI:1598556441
Name:MOORE, HAVALAH
Entity type:Individual
Prefix:
First Name:HAVALAH
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 STILL PASTURE LN
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27253-4281
Mailing Address - Country:US
Mailing Address - Phone:336-549-7302
Mailing Address - Fax:
Practice Address - Street 1:2608 ERWIN RD STE 200
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4597
Practice Address - Country:US
Practice Address - Phone:919-684-2471
Practice Address - Fax:919-681-1397
Is Sole Proprietor?:No
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004882133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered